p.1
Respiratory Distress and Management
What is the Berlin criteria used for?
To clinically define Acute Respiratory Distress Syndrome (ARDS).
p.2
Acute Kidney Injury and Oliguria
How is Acute Kidney Injury (AKI) defined according to the Acute Kidney Injury Network (AKIN)?
An increase in serum creatinine greater than 1.5x the baseline or an absolute rise of 0.3 mg/dL or more in a 48-hour period.
What can indicate hypovolemia in a postoperative patient?
Continued hypotension after a large amount of blood loss during surgery.
What are some general signs of shock and hypoperfusion?
Cool, pale skin, tachycardia, confusion or mental status changes, decreased urine output, and lactic acidemia.
p.1
Postoperative Infection and Bacteremia
What can cause bacteremia?
Any source of infection, with central line infections directly seeding the vascular space.
p.4
Acute Kidney Injury and Oliguria
What is a risk factor for developing postoperative Acute Kidney Injury (AKI)?
A history of chronic kidney disease.
p.1
Acute Kidney Injury and Oliguria
What symptoms can uremia cause?
Mental status changes, coma, pericarditis, nausea/vomiting, pruritus, and platelet dysfunction.
p.4
Laboratory and Imaging Tests in Postoperative Care
What are common laboratory tests for diagnosing respiratory distress?
CXR, ABG, EKG, echocardiogram, CT-angiography of the chest.
What is the treatment for atrial fibrillation with rapid ventricular response?
Correction of electrolytes, fluid overload with diuretics, and anti-arrhythmics; synchronized cardioversion if unstable.
What is used in septic shock to maintain adequate perfusion?
Norepinephrine, which primarily causes peripheral vasoconstriction.
p.9
Ileus and Bowel Obstruction
What is the management for ileus after ruling out mechanical obstruction?
Bowel rest, IV fluids, NG tube decompression, correction of electrolytes, and ambulation.
p.1
Acute Kidney Injury and Oliguria
What can prolonged oliguria lead to?
Fluid retention and overload, causing peripheral and pulmonary edema.
What defines hypotension in surgical patients?
A blood pressure below 90/60 mmHg or mean arterial pressure (MAP) below 65 mmHg.
p.4
Laboratory and Imaging Tests in Postoperative Care
What laboratory tests are used for evaluating Acute Kidney Injury (AKI)?
BMP, UA with microscopy, urine electrolytes, EKG, renal ultrasound.
p.4
Laboratory and Imaging Tests in Postoperative Care
What tests are necessary to diagnose adrenal insufficiency (AI)?
ACTH stimulation testing and cortisol levels.
p.4
Acute Kidney Injury and Oliguria
What does a low free cortisol level suggest?
It is suggestive of adrenal insufficiency, but can be affected by low protein levels.
p.4
Respiratory Distress and Management
What can arterial blood gas (ABG) analysis reveal?
Details about the cause and severity of respiratory distress.
p.4
Diagnostic Strategies for Postoperative Complications
What is a common laboratory test for wound complications?
CBC, wound culture, CT scan.
p.1
Respiratory Distress and Management
What are general signs of respiratory distress?
Tachypnea, use of accessory muscles, nasal flaring, chest retractions, inability to speak full sentences, grunting, shortness of breath, and cyanosis.
p.2
Acute Kidney Injury and Oliguria
What are the indications for acute hemodialysis in patients with AKI?
Refractory metabolic acidosis, electrolyte imbalances, clearance of toxins, volume overload, and uremia.
p.6
Acute Kidney Injury and Oliguria
What does a FeNa < 1% suggest?
Prerenal causes due to the kidney's ability to efficiently reabsorb sodium in response to renal hypoperfusion.
What should be done for a post-operative myocardial infarction?
Immediate Cardiology consultation and management including supplemental oxygen, analgesia, and nitroglycerin.
What is a common presentation of adrenal insufficiency in postoperative patients?
Hypotension refractory to adequate fluid resuscitation in patients with a history of chronic steroid use or Addison’s disease.
p.2
Ileus and Bowel Obstruction
What are the clinical signs of ileus?
Nausea, vomiting, lack of flatus and bowel movements, decreased bowel sounds, inability to tolerate a diet, and abdominal distension and pain.
p.2
Ileus and Bowel Obstruction
How can ileus be differentiated from mechanical bowel obstruction?
Through imaging and laboratory data.
p.9
Ileus and Bowel Obstruction
What may be required for prolonged ileus greater than 7 days?
Parenteral nutritional support.
p.7
Prevention and Management of Surgical Complications
What is the management for superficial abscesses?
They can often be drained by opening the skin and packing the wound with wet-to-dry dressings.
p.1
Acute Kidney Injury and Oliguria
How is oliguria defined in adults?
Less than 0.5 cc/kg/hour or 300 cc per 8-hour shift.
How is adrenal insufficiency treated postoperatively?
With administration of an IV hydrocortisone taper, termed stress dose steroids.
p.8
Respiratory Distress and Management
How can aspiration during induction of anesthesia be prevented in high-risk patients?
By NG tube decompression of the stomach prior to induction and rapid sequence intubation (RSI).
p.8
Respiratory Distress and Management
What is the purpose of cricoid pressure during intubation?
To compress the esophagus, preventing passive regurgitation.
p.8
Respiratory Distress and Management
What are some methods to prevent atelectasis, pulmonary edema, and pneumonia postoperatively?
Judicious fluid use, early mobilization, and cough and deep breathing exercises with incentive spirometry.
p.10
Stress Ulcers and Upper GI Bleeding
How are stress ulcers prevented and treated?
With proton pump inhibitors or H2 blockers to suppress acid secretion.
p.10
Stress Ulcers and Upper GI Bleeding
Who should receive prophylactic acid suppression for stress ulcers?
All severely ill patients at risk of stress ulcer formation.
p.8
Respiratory Distress and Management
What is the management strategy for ARDS?
Treating the underlying cause and using a lung-protective ventilation strategy with low tidal volumes.
p.5
Postoperative Infection and Bacteremia
What does an elevated white blood cell count (WBC) indicate?
It is an indicator of infection.
p.8
Acute Kidney Injury and Oliguria
How can contrast-induced nephropathy be prevented?
By prehydration and using intravenous bicarbonate and N-acetylcysteine.
p.5
Acute Kidney Injury and Oliguria
How can fractional excretion of sodium (FeNa) help in diagnosing AKI?
It differentiates prerenal acute kidney injury from other types.
p.3
Neurologic Complications Post-Surgery
What is a hallmark feature of delirium?
Fluctuating course affecting attention the most.
p.9
Acute Kidney Injury and Oliguria
What is the management for ureteral obstruction?
Percutaneous nephrostomy tube drainage of the renal pelvis.
What is a common management for bleeding from skin edges?
Holding direct pressure, packing the wound with hemostatic agents, or placing a suture across the bleeding vessel.
p.1
Respiratory Distress and Management
What imaging findings are expected in patients with aspiration pneumonia?
Pathology in the right middle and lower lobes.
p.6
Diagnostic Strategies for Postoperative Complications
What imaging should be done for patients presenting with ileus?
An abdominal acute series, including upright chest x-ray, upright abdominal x-ray, and supine abdominal x-ray.
p.5
Diagnostic Strategies for Postoperative Complications
What can hypocapnia indicate in a patient?
It can be seen with tachypnea due to hyperventilation.
p.5
Laboratory and Imaging Tests in Postoperative Care
What does a basic metabolic panel (BMP) check for?
Electrolytes, blood urea nitrogen (BUN), and creatinine (Cr) to determine kidney injury.
p.6
Diagnostic Strategies for Postoperative Complications
What is the purpose of lower extremity venous duplex ultrasound?
To diagnose deep vein thrombosis.
p.6
Acute Kidney Injury and Oliguria
What is the role of renal ultrasounds in severe AKI?
To rule out hydronephrosis associated with post-renal obstructive renal injury.
p.5
Diagnostic Strategies for Postoperative Complications
Why are cardiac enzymes checked in patients with postoperative hypotension?
To rule out myocardial infarction (MI) and arrhythmias.
p.10
Neurologic Complications Post-Surgery
Which medications can be used to treat hyperactive symptoms of delirium?
Antipsychotic agents such as haloperidol or quetiapine.
p.7
Prevention and Management of Surgical Complications
Do pneumonia and simple cellulitis require source control?
No, they do not require source control.
p.10
Neurologic Complications Post-Surgery
What type of rehabilitation do stroke patients often require?
Physical therapy and stroke rehabilitation.
p.3
Neurologic Complications Post-Surgery
What are common signs of stroke?
Facial droop, aphasia, and limb weakness.
p.4
Diagnostic Strategies for Postoperative Complications
What should be considered if a patient has a fever after abdominal surgery with GI content spillage?
Abscess should be higher on the differential.
What should be assessed in postoperative patients presenting with hypotension?
Ongoing bleeding, which can progress to hemorrhagic shock.
p.7
Prevention and Management of Surgical Complications
When should prophylactic antibiotics be administered before surgery?
Within 30-60 minutes prior to skin incision.
p.7
Prevention and Management of Surgical Complications
What should be done with grossly contaminated wounds?
They should be kept open with wet-to-dry dressings.
p.10
Stress Ulcers and Upper GI Bleeding
What interventions may be required for severe bleeding from stress ulcers?
Endoscopy with application of hemostatic agents, clipping, or cautery.
p.6
Prevention and Management of Surgical Complications
What are some methods to prevent wound infections?
Adequate skin prep, chlorhexidine washes, clipping hair, preoperative antibiotics, glycemic control, and tobacco cessation.
p.10
Neurologic Complications Post-Surgery
What should be done if a patient presents with a stroke after carotid endarterectomy?
They may need to be taken back to the OR emergently to assess the carotid artery for technical complications.
p.10
Neurologic Complications Post-Surgery
What therapy may be appropriate for some patients with acute strokes?
IV thrombolytic therapy with alteplase (tPa).
p.3
Stress Ulcers and Upper GI Bleeding
What are the markers of severity in upper GI bleeding?
Hemodynamic instability and drop in hemoglobin.
p.6
Diagnostic Strategies for Postoperative Complications
What can an upright chest x-ray reveal in cases of intestinal perforation?
Free air under the diaphragm.
p.6
Diagnostic Strategies for Postoperative Complications
When should abdominal CT scans be performed?
When deep wound infection, intra-abdominal abscess, anastomotic leak, or prolonged ileus is suspected.
p.8
Respiratory Distress and Management
What role does adequate analgesia play in postoperative care?
It prevents atelectasis, pulmonary edema, pneumonia, and promotes early mobility by reducing splinting from pain.
p.8
Respiratory Distress and Management
How should pneumonia be treated in postoperative patients?
With broad-spectrum antibiotics that cover both pseudomonas and MRSA.
p.6
Neurologic Complications Post-Surgery
What is the significance of transthoracic echocardiography (TTE) in postoperative care?
It evaluates LV function, diagnoses structural causes of arrhythmias, and assesses right heart strain.
p.7
Prevention and Management of Surgical Complications
What is a key principle in managing infections postoperatively?
Source control is usually necessary for successful treatment.
p.5
Acute Kidney Injury and Oliguria
What does the presence of muddy brown casts in urinalysis suggest?
Acute tubular necrosis (ATN), the most common type of intrinsic AKI.
p.10
Neurologic Complications Post-Surgery
What is important to evaluate in stroke patients to prevent aspiration events?
The patient’s speech and swallow function.
p.3
Neurologic Complications Post-Surgery
What should be evaluated in a patient presenting with delirium?
The underlying medical condition or substance causing it.
p.3
Diagnostic Strategies for Postoperative Complications
Why is interviewing the patient important in postoperative care?
It provides details about the presence and timing of symptoms associated with complications.
p.5
Prevention and Management of Surgical Complications
What should be obtained for a fever workup in postoperative patients?
Blood cultures to diagnose bacteremia and ensure appropriate antibiotics.
p.10
Neurologic Complications Post-Surgery
What are some actions to prevent or improve symptoms of delirium?
Avoid problematic medications, use orientation protocols, restore sleep patterns, and ensure regular family visits.
p.5
Acute Kidney Injury and Oliguria
What does lactate measurement indicate in patients with shock?
It is a marker of inadequate tissue oxygenation and hypoperfusion.
p.5
Postoperative Infection and Bacteremia
What does a urinalysis positive for nitrites, leukocyte esterases, and bacteria suggest?
It is highly suggestive of a urinary tract infection (UTI).
p.3
Stress Ulcers and Upper GI Bleeding
How can nasogastric tube lavage help differentiate between upper and lower GI bleeds?
If the NG tube returns blood, it's an upper GI bleed; if it returns bile, it's a lower GI bleed.
p.7
Prevention and Management of Surgical Complications
What indicates malnutrition in a preoperative patient?
A preoperative albumin of less than 3.5 g/dL.
p.8
Acute Kidney Injury and Oliguria
What is the initial treatment for AKI?
Correcting renal hypoperfusion with IV hydration and removing nephrotoxic agents.
p.10
Neurologic Complications Post-Surgery
What is often required for the management of acute strokes?
Neurology and sometimes Neurosurgery consultation.
p.3
Stress Ulcers and Upper GI Bleeding
What are the symptoms of stress gastritis and ulceration?
Coffee ground emesis, hematemesis, or melena.
p.3
Diagnostic Strategies for Postoperative Complications
What is the first step in approaching a patient with a postoperative complication?
Performing a careful history and physical examination.
p.8
Respiratory Distress and Management
What are the preventive measures for pulmonary embolism and DVTs?
Early ambulation, prophylactic doses of heparin, and intermittent compression hose.
p.3
Stress Ulcers and Upper GI Bleeding
What indicates a potential upper GI bleed during NG tube lavage?
The return of gastric fluid without bile is considered equivocal.
